Pain Assessment
By: Bram Riegel, M.D.

Introduction:

The goal of the initial pain assessment is to characterize an
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individual's pain by location, intensity, and etiology. A pain assessment should include a detailed history, physical examination, psychological assessment, and diagnostic evaluation. But the single most reliable indicator of the existence and intensity of pain is the patients self-report of pain. The patients' report of pain should be the primary source of information, since it is more accurate than the observations or others.

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The American Pain Society guidelines for the treatment of acute and cancer pain suggest that each of the following assessment steps occur.

1. The patient's self-reported pain is charted and displayed.

2. The intensity of pain and discomfort are assessed and documented at regular intervals (i.e. prior to administration of medication and then after administration of medications)

3. The degree of pain intensity is measured after allowing sufficient time to pass in order to ensure that a specific pain intervention treatment has occurred.

The New Joint Commission Standards also highlight the need for comprehensive pain assessment in all individuals (not just patients in acute pain and cancer pain). Pain assessment should occur if pain is identified during the initial pain assessment. A more comprehensive pain assessment is performed when warranted by the patient's condition. The results of this more comprehensive pain assessment, including a measurement of pain intensity and quality, are recorded so that regular assessment and follow up can occur.

The Patients Right to Pain Assessment

The Joint Commission Standard asserts that patients served "have that right to appropriate assessment and management of pain". This acknowledges that although pain can be a common experience, unrelieved pain has adverse physiological and psychological effects. Therefore, staff must respect and support each

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right to pain management. To fulfill the patient's right to pain assessment, the following steps are taken:

1. Initial pain assessment and regular reassessment of pain.

2. Education of healthcare providers with regards to pain assessment and management.

3. Education of patients with pain and their families when appropriate.

4. Communication to patients and families that pain management is an important aspect of care.

A healthcare organization can implement the standard in several different ways with the goal being that each patient's pain is recognized and treated appropriately. One approach would be asking every patient screening questions regarding pain on admission (i.e. do you have pain now? And have you had pain in the past several weeks or months?). An alternative approach would be to consider Pain the Fifth Vital Sign. This means that staff would assess and record pain intensity along with temperature, pulse, respiration, and BP. In both approaches, the patient may say yes and admit to pain. This behooves staff to provide additional pain assessment.

Assessment

1. Pain intensity using a pain intensity rating scale appropriated for the patient's age. Pain intensity rating should be attained for pain now, worse pain, and least pain.

2. Location: The patient should be asked to mark the site or sites of pain on a pain diagram.

3. Quality and patterns of radiation.

4. Onset duration and variation of patterns.

5. Alleviating and aggravating factors.

6. Present pain management regimen and effectiveness.

7. Pain management history including medication history.

8. Effects of pain on daily functions.

9. The patient's pain goal.

10. Physical examination.

Pain Assessment Techniques

The patient's self-reported pain is often measured by using pain scales. A variety of pain scales exist. See Numeric Pain Intensity Scale, Simple Descriptive Pain Intensity Scale, Visual Analog Scale (VAS), and Wong-Baker Faces Pain Intensity Scale. Whichever pain scale is used, it should be reliable, valid, and geared toward the patient.

Numeric Pain Intensity Scale uses a 0-10 scale to assess the degree of pain. Simple Description Intensity Scale, uses such words as "mild", "moderate", and "severe" to describe the patient's pain intensity. Visual Analog Scale (VAS) requires patients to mark a point on a 10 cm horizontal or vertical line to indicate their pain intensity, with 0 indicating "no pain" and 10 indicating "the worst possible pain".

Patient may have pain at more than one site and should be encouraged to report as many sites that are relevant. Healthcare organizations may need to utilize more than one pain intensity scale based on the needs of its various patients. Adults should be encouraged to use those 0-10 numeric scales. If they are unable to understand or unwilling to use this scale, the Wong-Baker Pain Faces Scale can be used. A healthcare organization serving both adults and children could use two scales, one for each of its populations.

Pain Assessment Tailored to Distinct Populations

Different populations
have different pain. Therefore different pain assessment techniques and management strategies will be appropriate depending on the population. Five general populations will be discussed: elderly (burn survivors), infants and children (burn survivors), cancer and AIDS patients, patients at the end of life, and patients who have difficulty communicating (burn survivors).

Elderly

Many elderly patients, including ones that were burned, suffer from conditions that are a source of chronic pain, such as arthritis, bone and joint disorders, back problems, gout, and peripheral vascular disease. Many of those patients believe that pain is a normal consequence of that aging process. Many elderly patients are reluctant to report pain due to several myths on the elderly and people complain of pain and are unreliable pain reporters. Finally, many elderly fear being perceived as bothersome, hypochondriacs, or addicts. All of these contribute to the likelihood that pain will be under reported in many elderly patients.

Infants and Children

Pediatric patients are often under treated for post op pain. Part of the reason for under medication maybe that children exhibit and cope with pain differently than adults do. They may be less verbal that adults. Children may exhibit a wide range of responses to pain as: crying or fussing, making a distressed face, holding or touching a place that hurts, become very quite, or sleep excessively.

The healthcare staff may need to use a pain assessment tool designed for children, such as the Wong-Baker Faces pain scale. However, even a face scale will not help determine an infant's level of pain. The staff must rely on contextual information, diagnosis, and the infant's response to routine comfort measures for determining an infant's pain level. The staff must also learn to assess facial expressions, body movements, crying, groaning, and/or changes in vital signs. The Barrier and Attia's Observational Instrument and the Modified Infant Pain Scale have been used to accurately assess pain in this age group.

Patients with AIDS and Patients with Cancer

Although patients with AIDS suffer pain comparable to that of patients with cancer, the former patients are twice as likely to be under treated for pain. One reason is that the focus tends to be on treating potentially reversible problems such as quelling and opportunistic infection. In addition, certain drugs that fight the opportunistic infections also cause neuropathic pain syndromes in HIV patients. Patients with cancer can have transient pain, long-term pain or both. Pain can be related to either the disease process or treatment.

Patients at the End of Life

There is no data to show that fostering effective pain management for patients at the end of life shortens life. On the other hand, in all instances where the primary care of therapy is to alleviate pain and suffering and not to promote death, pain management is deemed to be ethical and appropriate. When pain and suffering are resistant to treatment, sedation may be therapeutic and medically appropriate to provide pain relief, but only if this is consistent with the wishes of the patient.

Patients with Difficulty Communicating

Adults who have difficulty communicating their pain require special consideration. This group includes patients with cognitive or sensory impairments as well as patients who do not verbally communicate pain or do not speak English. As with infants and children, cognitively impaired patients may signal pain or discomfort via behavioral factors.

Assessment and Reassessment of Pain

Pain should be assessed and reassessed at regular intervals to ensure that the individual's pain is being relieved. Patients with acute pain (i.e. patients who have just had surgery), the frequency of pain assessment can be based on the type of surgery performed and the severity of pain. For patients with chronic pain (i.e. patients with burns, cancer or arthritis), healthcare providers should evaluate pain every time the patient is assessed. Subsequent pain assessment should involve the clinician evaluating the effectiveness and management plan. If pain is not relieved, the clinician should determine whether the pain is related to the progression of the disease, vs. being related to a new cause, vs. being related to the treatment.

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